Preventing, Assessing, and Managing Constipation in Older Adults

Preventing, assessing, and managing constipation in older adults

By Francis Toner, BSN, RN, and Edith Claros, PhD, MSN, RN

UP TO HALF OF ALL older adults This article describes how nurses experience any discomfort or (24% to 50%) suffer from consti- can prevent, assess, and manage harmful effects. pation. From 10% to 18% of older constipation to promote the highest The population of those 65 and adults who live in the community level of health and functionality for older is expected to increase to and 74% of residents in long-term their patients. 88.5 million by 2050; those 85 and care use laxatives every day.1 older will double to 9.6 million Constipation, one of the five Distressing problem during the same period.7 Nurses most commonly diagnosed condi- Constipation is commonly will care for a higher percentage of tions in outpatient visits, is a signifi- described as infrequent bowel older adults with chronic condi- cant and potentially costly problem movements, straining for a tions such as constipation. Potential because of the expense of over-the- movement, a decrease in volume or health-related consequences of con- counter medications, healthcare weight of stool, a sense of incom- stipation, such as impaired quality provider office visits, ED and re- plete evacuation, or dependence on of life, fecal impaction, and inconti- lated hospital admissions, specialty laxatives, enemas, or suppositories nence, make it a significant public referrals, and associated surgical to maintain regular bowel move- health issue for older adults.6,8 procedures.1,2 ments.5 Regularity of normal bowel Age-related changes affecting movements varies from person Understanding the the gastrointestinal (GI) system, to person, from three times daily pathophysiology including decreased peristalsis and to three times weekly.6 Patients Stool volume and consistency are altered acid secretion, are often who meet Rome III diagnostic determined by fluid content; nor- overlooked.3 Constipation reduces criteria guidelines may be diag- mally, water volume accounts for

patients’ quality of life. Depression, nosed with functional constipation, 70% to 85% of total stool weight. HOTO P anxiety, decreased social activities, a classified GI disorder. (More on Stool fluid volume reflects a balance TOCK S I and pain can significantly under- these guidelines later.) Some between luminal input by ingestion / mine their physical and mental patients who don’t have a bowel and absorption along the GI tract.9,10

2,4 AKOBCHUK well-being. movement for several days don’t (See Focusing on the GI system.) Y

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. For an adult, normal fluid intake 1.5 L pass through the ileocecal valve tion and moves luminal contents varies depending on the amount of to the colon. The colon absorbs most along the GI tract. Mixing in the calories spent for energy. For exam- of the remaining fluid, leaving about colon is accomplished by short- or ple, someone consuming 1,800 calo- 100 mL of fecal fluid daily to be long-duration stationary contrac- ries will need 1,800 mL of water added to the total daily stool output, tions or nonpropulsive contrac- intake to meet metabolic demands. which is about 200 mL.9,10 Fluid tions. Fecal movement in the colon During a 24-hour period, the absorption by the intestinal epithe- is accomplished by propulsive con- amount of fluid intake in a normal lium is directly influenced by transit tractions known as high-amplitude adult averages 2,600 mL.11 The main time, or colonic motility. propagating contractions. These function of the small intestine is wa- Colonic motility mixes luminal strong colonic pressure waves, ter absorption; it lets only about 1 to contents to promote water absorp- which originate from variable sec- tions of the colon and travel toward Focusing on the GI system the rectum, are the main mechanism for transferring feces from the right to left colon once or twice daily.12 Decreased motility of propulsive contractions causes the feces to remain stationary and can lead to constipation. Increased motility of nonpropulsive contractions increases fecal mixing and fluid absorption, Oral cavity Parotid gland also causing constipation. Decreased Sublingual and and duct motility and excess fluid removal submandibular Pharynx can lead to feces becoming inspis- glands and ducts Esophagus sated and impacted, causing constipation.9

Classifying constipation Constipation is classified into three basic pathophysiological categories: normal transit, slow transit, and disorders of defecation. • Normal-transit constipation (or Liver functional constipation) is defined as perceived difficulty in defecation. Hepatic duct Stomach It usually responds positively to Gallbladder noninvasive treatments, such as Splenic flexure Duodenum increasing fluid and fiber intake, engaging in moderate exercise, and Hepatic flexure Transverse colon setting regular bowel patterns, usually after a meal when colon activity Jejunum Pancreas is at a peak.11 Patients experience Descending colon Ascending colon this type of constipation due to an Ileum inability to evacuate stool from the Ileocecal junction rectum, even though stool traverses at Cecum a normal rate and frequency may Sigmoid colon Appendix remain normal. Common causes for Rectum functional constipation include inadequate fluid and fiber intake, inactivity and bed rest, abdominal muscle weakness, failure to respond

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. to defecation urges, a change in What factors contribute to constipation?2,6,28 bowel patterns, hemorrhoids, and pregnancy. This is not an all-inclusive list. • Slow-transit constipation (STC) is Medications Diseases Foods defined as infrequent bowel movements caused by an alteration in Aluminum antacids Amyloidosis Caffeine intestinal innervation.11 Also known Anticholinergics Chronic idiopathic intestinal Dairy products pseudoobstruction as colonic inertia, STC results in Antidepressants Fast foods slowed intestinal transit and impaired Dementia colonic contractions due to dysfunc- Antihistamines Fatty meats Depression tional colonic intrinsic reflex mecha- Barium Packaged foods nisms.13 The causes of STC aren’t well Diabetes or poor glycemic control Calcium antacids Processed foods understood. However, Hirschsprung Diverticulosis disease is an extreme form of STC Calcium channel Refined white flour characterized by narrowing of the blockers Hirschsprung disease and rice bowel due to a lack of ganglion cells Calcium supplements Hypercalcemia Sucrose in the distal bowel caused by a defect Diuretics Hypothyroidism Wheat and white during embryonic development.11 bread • Defecation disorders are charac- Iron supplements Lupus terized by a dysfunction of the anal Levodopa Multiple sclerosis sphincter or pelvic floor hypertonic- ity, known as dyssynergia.14 Though Opioids Parkinson disease less common, structural abnormali- Psychotropics Scleroderma ties such as rectal prolapse, intussus- Spinal cord injury ception, rectocele, and perineal descent can lead to defecation Stroke 6,15 disorder. Uremia Constipation can be caused by a primary disorder of intestinal motility or by a secondary cause, the patient can’t meet the criteria for and present and past bowel regi- such as an adverse reaction to a irritable bowel syndrome and rarely mens. Also assess for diet and fluid prescribed medication. In addition, it has loose stools without using laxa- intake, patient mobility, obstetric/ may appear as a direct symptom of tives. Additionally, two or more of the gynecologic history, surgical history, obstructing lesions of the GI tract or following symptoms must be present medication history, associated dis- as a complication of a disease such as during at least 25% of defecations: eases that may affect bowel motility, hypothyroidism. Chronic constipa- • straining and alterations in perianal sensation. tion is associated with neurologic, • lumpy or hard stools Determine any patient misconcep- endocrine, systemic, and metabolic • sensation of incomplete evacua- tions regarding bowel habits. disorders.11 (For more details, see tion Encourage the patient to keep a What factors contribute to • sensation of anorectal obstruction/ 7- to 14-day diary of bowel habits, constipation?) blockage noting time of day, frequency, stimuli • manual maneuvers to facilitate causing defecation, stool characteris- Arriving at a diagnosis defecation tics, and any aids and/or maneuvers The Rome III diagnostic criteria are • fewer than three defecations per needed during defecation. For new- effective in determining functional week.16 onset constipation, determine if the constipation in a patient experiencing Diagnosis is based on the patient’s patient has recently stopped smok- associated constipation symptoms history, physical manifestations, and ing. Smoking cessation causes consti- that persist for at least 3 months with test results. The history should in- pation in one in six people and can symptom onset at least 6 months be- clude the patient’s defecation pattern, sometimes be very severe.17,18 fore diagnosis. To meet diagnostic including time of day, frequency, When performing medication rec- criteria for functional constipation, amount and consistency of stool, onciliation, assess the relationship www.Nursing2012.com December l Nursing2012 l 35

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. between the start of a medication balloon expulsion tests, help clini- and the onset of constipation symp- cians diagnose constipation caused toms.18 Pay careful attention to by abnormal anal or rectal function- medications that are known to cause ing.19 During anorectal manometry, constipation as an adverse reaction, an air-filled balloon, also known as a such as opioids. For patients receiv- radial catheter, is inserted into the ing temporary opioids, request anus 6 to 8 cm (2.4 to 3.1 in.) above stool softeners and/or laxatives if the anal verge (the distal end of the constipation develops. For patients anal canal, forming the transitional receiving round-the-clock opioids zone between the skin of the anal for palliative care, speak with the canal and the perianal skin), then provider about the possibility of slowly pulled back to evaluate anal adding methylnaltrexone or alvimo- sphincter function. The test mea- pan. These drugs block opioid effects sures muscle tone, luminal pressure, on the GI tract without interfering and contractions.19,22 with analgesia.17 The balloon expulsion test is After documenting the patient’s Because fecal impaction can conducted by inserting a balloon history, perform a physical assess- manifest as delirium in catheter into the rectum and filling ment. First inspect the abdomen, older patients, be sure to the balloon with varying amounts of then auscultate for bowel sounds, assess patients with a water. The patient is then asked to percuss for dullness, and palpate for change in mental status for expel the water-filled balloon; inabil- masses. Constipation often causes this problem. ity to expel a balloon of less than the abdomen to become distended 150 mL of water indicates a decrease and tender, and stool in the colon in bowel function.19 Another ap- causes a dull percussion note.17 plained weight loss up to or exceed- proach to assess defecation dysfunc- If a digital rectal exam is indi- ing 10 lb (4.5 kg), anemia, positive tion involves a 50-mL water-filled cated, try to identify any fissures or fecal occult blood tests, family his- balloon. If the patient can expel the hemorrhoids, which can be caused tory of colon cancer or inflammatory balloon in less than 1 minute, a by constipation or which can cause bowel disease, and an acute onset of dysfunction is unlikely.18 secondary constipation due to stool constipation in older adults. It may The colorectal transit study retention from the pain. Check require invasive testing at the discre- measures how long it takes food to for a gaping or asymmetric anal tion of the healthcare provider.19,20 travel through the colon. During the opening, characteristics of a neuro- Pertinent lab test results should study, the patient eats a high-fiber logic disorder impairing the anal be made available to the healthcare diet after swallowing radiopaque sphincter. provider, especially for patients who markers. Movement of the markers is Try to evaluate the puborectalis have emergent signs or symptoms. recorded by abdominal X-rays taken and external anal sphincter muscles’ Lab data should include a complete several times daily for 3 to 7 days.19 function by asking the patient to blood cell count and serum glucose, Defecography evaluates rectal strain during the exam. This may calcium, creatinine, and thyroid- muscle contractions and relaxation help identify a patient with possible stimulating hormone levels.18 and completeness of stool elimina- dyssynergic defecation.18 Assess for Diagnostic studies for constipation, and identifies anorectal abnor- impaction, especially in patients tion may be indicated and can malities. Defecography is performed with spinal cord compression and include anorectal function tests, by placing 150 mL of barium into advanced multiple sclerosis.17 colorectal transit studies, and defe- the patient’s rectum and monitoring Tell patients to consult a health- cography (evacuation proctogra- the route of evacuation by fluoros- care provider if signs and symptoms phy).21 Studies to rule out colorectal copy while the patient sits on a of constipation persist for 3 weeks or cancer may include a barium enema specially constructed commode. more and to consult one immediately X-ray, sigmoidoscopy, and colonos- The patient is asked to squeeze, if they see blood in the stool.10 Emer- copy. cough, and bear down so the gent signs and symptoms include Anorectal function studies, which anorectal structures can be visually hematochezia, sudden or unex- include anorectal manometry and assessed.18,19

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Diagnostic study results help determine the most effective course Close-up on methylnaltrexone of treatment. A relatively new drug, methylnaltrexone is used for the treatment of OIC. It has its own classification, which means that it’s not a laxative. The drug was developed to Treating the problem target the primary cause of OIC in adults with advanced illness who are being Bowel regularity is affected by diet, treated with opioids for chronic pain. medication use, disease, and habit.11 Methylnaltrexone works by displacing the opioid from the peripheral mu Depending on the cause, treatment receptors that affect GI tract motility. This reverses constipation at its source without disrupting the opioid’s analgesic effect. The drug doesn’t cross the for constipation may include non- blood-brain barrier. Methylnaltrexone is administered subcutaneously based on pharmacologic and pharmacologic body weight, once every other day as needed. Because it provides predictable, measures. Standard treatments include quick results, patients using this drug don’t need further bowel interventions.30 increasing fiber and fluid intake, exercising, avoiding constipation- causing drugs, and instituting • Osmotic laxatives, such as low-dose Glycerin suppositories, which can appropriate bowel training and polyethylene glycol and saline laxa- increase water retention and stimulate biofeedback.6 tives, aren’t absorbed in the intestine; peristalsis, usually produce a bowel Treatment should begin with the instead, they pull water into the fecal movement in less than an hour.9 least invasive options, such as diet mass to create more watery stool.6 Enemas, an invasive treatment, cause and lifestyle modifications.14 These • Stimulant laxatives, such as senna the distal colon or rectum to empty are appropriate for both acute and and bisacodyl, irritate the bowel to any retained solid material through chronic constipation. increase peristalsis.6 bowel distention, producing an Diet recommendations include • Stool softeners or surfactants, such evacuation reflex in most people.9 consuming 60 to 80 oz (1.8 to 2.4 L) as docusate, cause more water and Long-term or chronic use of of fluid and 25 to 30 g of fiber daily fat to be absorbed into the stool.6 enemas and/or laxatives can interfere unless contraindicated to promote • Miscellaneous agents include min- with the defecation reflex and may healthy bowel movements.14 Reach- eral oil, which acts by lubricating the damage the rectal mucosa, leading to ing the daily recommended fiber in- stool and colon mucosa.14 diarrhea and fecal incontinence.11 take can be achieved by adding foods For patients with opioid-induced This can cause such adverse reactions such as bran, shredded wheat, constipation (OIC) or dysfunction, as electrolyte abnormalities, bloating, whole-grain breads, and certain prevention strategies alone won’t be flatulence, and cramping.2 (See “Fleet fruits and vegetables.5 sufficient. These patients require a enemas: Don’t underestimate the risk” Adding the “colon cocktail” to a bowel regimen that combines a stool on page 12.) Because laxatives are patient’s diet can maintain stool con- softener and stimulant medications, linked to weight loss and malnutri- sistency. This usually consists of equal such as docusate and senna, accom- tion, increasing dietary intake of oat portions of prune juice, applesauce, panying the opioid prescription. and fiber is a better approach. 25 Fiber and psyllium, a common form of Bulk laxatives aren’t recommended intake should be increased gradually bran. The cocktail is refrigerated, and in patients with OIC due to im- because a rapid increase may cause the patient takes 1 to 2 tablespoons paired peristalsis.6,14,23 OIC can excessive gas production and (15 to 30 mL) daily. Promoting also be managed by using peripher- bloating. proper bowel function helps prevent ally acting mu-opioid receptor an- constipation by regulating proper tagonists such as methylnaltrexone On alert for complications formation and frequency of stool.14 and alvimopan. These types of med- Complications of constipation If nonpharmacologic treatments ications provide pain relief while include hemorrhoids, anal fissures, are inadequate, laxatives may be minimizing the effects of opioids rectal prolapse, intestinal obstruc- added to the treatment regimen.14 on GI motility.24 (See Close-up on tion, and fecal impaction.6 Laxatives are classified into one of methylnaltrexone.) Fecal impaction occurs when hard five primary groups. A bowel regimen may consist of a stool packs the intestine or rectum • Bulk-forming laxatives, such as step-level approach in which medi- so tightly that stool can’t be expelled. psyllium seed and methylcellulose, cation combinations are prescribed It’s more prevalent in women and absorb water, adding to the size of based on the patient’s response to older adults.19 After ruling out bowel the fecal mass.14 treatment. perforation or bleeding, treatment www.Nursing2012.com December l Nursing2012 l 37

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. begins by softening the stool with Nursing considerations water intake, as tolerated. Adding mineral oil or an enema, placing the Nurses are in an ideal position to fiber products such as oat bran to patient in Sims’ position, then insert- identify patients at risk for constipa- the diet can decrease patients’ de- ing one or two lubricated gloved fin- tion and to assess for signs and pendence on laxatives while helping gers into the anus and breaking up symptoms. Obtain the patient’s them maintain a healthy body the feces. In older adults, severe fecal health history, noting risk factors weight.25,29 Educate them about foods impaction can lead to intestinal ob- such as inadequate fluid intake, that are high in fiber. (See Selecting struction, a medical emergency.26 decreased mobility, and comorbid high-fiber foods.) Because fecal impaction can manifest conditions. Assess the patient’s diet, Consuming fiber improves bowel as delirium in older patients, be sure including fiber intake. Perform function and regularity, increases to assess a patient with a change in medication reconciliation, including bowel movement frequency, im- mental status for this problem and to the use of over-the-counter medica- proves stool consistency, and reduces identify and prevent any potential tions and herbal supplements. Look painful straining. The use of fiber causes of constipation, including a for anything that may contribute to has been shown to reduce the costs review of medications that can constipation or be used for self- of treatment.14,23,26 aggravate the condition. In inpatient treatment, such as laxatives.27 As the patient’s primary advocate, settings, provide access to and Ask about the patient’s oral nurses have the responsibility to assistance with toileting regularly to health; changes in appetite; patterns protect and foster the patient’s prevent constipation and to maintain of bowel movements; consistency, well-being. By reducing laxative use, a bowel regimen. color, and size of the stool; seepage nurses also help reduce the risk of of stool; degree of straining during adverse reactions. Nurses are in an bowel movements; ignoring the urge ideal position to inform patients that Selecting high-fiber to defecate; and nausea, vomiting, dietary and lifestyle modification foods or other GI complaints.3 can be a simple and cost-effective ■ Legumes, nuts, and seeds Ask about the patient’s living intervention. Split peas conditions—for example, whether Lentils the patient lives alone or with family REFERENCES Black beans or friends—and the patient’s ability 1. Rao SS, Palagummi NM. Constipation in the Lima beans for self-care, including toileting, older adult. UpToDate. 2012. http://www.uptodate. Baked beans, vegetarian bathing, and dressing. Also assess com. 2. Rao SS, Go JT. Update on the management of Vegetables the patient for eating or swallowing constipation in the elderly: new treatment options. Artichoke difficulties that may contribute to Clin Interv Aging. 2010;5:163-171. Peas weight loss, changes in skin integrity 3. Mauk KL. Gerontological Nursing: Competencies for Care. 2nd ed. Sudbury, MA: Jones & Bartlett Broccoli (such as hemorrhoids, anal fissures, Publishers; 2010. Turnip and skin ulcerations), and risk of 4. Belsey J, Greenfield S, Candy D, Geraint M. Sweet corn falls in patients who use laxatives.3 Systematic review: impact of constipation on quality of life in adults and children. Aliment Grains, cereals, pasta Educate patients about decreasing Pharmacol Ther. 2010;31(9):938-949. Whole-wheat spaghetti their use of laxatives to prevent 5. American Society of Colon and Rectal Surgeons. Barley adverse reactions associated with Constipation. 2009. http://www.fascrs.org/ Bran flakes chronic laxative use. Encourage pa- patients/conditions/constipation/. Oat bran muffin tients to make lifestyle modifications 6. Gallagher PF, O’Mahony D, Quigley EM. Management of chronic constipation in the elderly. Oatmeal that help improve GI functioning, Drugs Aging. 2008;25(10):807-821. Fruits such as increasing physical activity. 7. U.S. Census Bureau. Profile America Facts for Encourage patients to follow a bowel Features. Older Americans Month: May 2011. Raspberries http://www.census.gov/newsroom/releases/ Pear with skin training regimen promoting defeca- archives/facts_for_features_special_editions/ Apple with skin tion in the morning, particularly cb11-ff08.html. Strawberries 8. Wald A, Scarpignato C, Kamm MA, et al. The about 90 minutes after meals or dur- burden of constipation on quality of life: results of Orange ing the gastrocolic reflex (the reflex a multinational survey. Aliment Pharmacol Ther. Adapted from Mayo Clinic staff. Nutrition and stimulating peristalsis after a meal).28 2007;26(2):227-236. healthy eating. High fiber foods. 2009. http:// 9. Parker LL. Goodman and Gilman’s The www.mayoclinic.com/health/highfiberfoods/ Promote nonpharmacologic mea- NU00582. See website for further detail. Pharmacological Basis of Therapeutics. 12th ed. New sures, including increasing fiber and York, NY: McGraw-Hill; 2011.

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 10. McCrea LG, Miaskowski C, Stopts NA, Macera 18. Wald A. Etiology and evaluation of chronic 25. Sturtzel B, Elmadfa I. Intervention with dietary L, Varma MG. Pathophysiology of constipation in constipation in adults. UpToDate. 2012. http:// fiber to treat constipation and reduce laxative use the older adult. World J Gastroenterol. 2008;14(17): www.uptodate.com. in residents of nursing homes. Ann Nutr Metab. 2631-2638. 2008;52(suppl 1):54-56. 19. National Digestive Diseases Information 11. Porth CM. Essentials of Pathophysiology: Concepts Clearhouse. Constipation. 2007. http://digestive. 26. Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. of Altered Health States. 3rd ed. Philadelphia, PA: niddk.nih.gov/ddiseases/pubs/constipation/. Brunner and Suddarth’s Textbook of Medical Surgical Nursing. 12th ed. Philadelphia, PA: Wolters Kluwer Wolters Kluwer Health/Lippincott Williams and 20. Ternent CA, Bastawrous AL, Morin NA, Ellis Health/Lippincott Williams and Wilkins; 2010. Wilkins; 2011. CN, Hyman NH, Buie WD; Standards Practice 12. Tack J, Müller-Lissner S, Stanghellini V, et al. Task Force of The American Society of Colon and 27. National Institute on Aging. Health and Aging. Diagnosis and treatment of chronic constipation—a Rectal Surgeons. Practice parameters for the Age Page. Concerned about constipation? 2008. European perspective. Neurogastroenterol Motil. 2011; evaluation and management of constipation. Dis http://www.nia.nih.gov/health/publication/ 23(8):697-671. Colon Rectum. 2007;50(12):2013-2022. concerned-about-constipation. 13. Ginsberg DA, Phillips SE, Wallace J, Josephson 21. Ziya Balta A, Demirbas S, Ozturk R, Yucel E, 28. Spinzi GC. Bowel care in the elderly. Dig Dis. KL. Evaluating and managing constipation in the Tahir Ozer M, Ersoz N. Constipation as a 2007;25(2):160-165. elderly. Urol Nurs. 2007;27(3):191-200. defecation disorders: what do we expect from 29. Sturtzel B, Mikulits C, Gisinger C, Elmadfa I. the physiologic tests? Bratisl Lek Listy. 2011; Use of fiber instead of laxative treatment in a 14. Moharana DN, Moharana S. Constipation. Q 112(1):34- 40. Med Rev. 2011;(62):1-31. http://www.raptakos.com/ geriatric hospital to improve the health of seniors. QMR_Apr_Jun_2011.pdf. 22. Cho HM. Anorectal physiology: test and J Nutr Health Aging. 2009;13(2):136-139. clinical application. J Korean Soc Coloproctol. 30. Canham J. Using methylnaltrexone in opioid- 15. Rao SS, Seaton K, Miller M, et al. Randomized 2010;26(5):311-315. controlled trial of biofeedback, sham feedback, and induced constipation. Nurse Prescribing. 2009; standard therapy for dyssynergic defecation. Clin 23. Lindberg G, Hamid S, Malfertheiner P, et al. 7(4):154-159. Gastroenterol Hepatol. 2007;5(3):331-338. World Gastroenterology Organization. Constipation: a global perspective. 2010. http:// Francis Toner is an OR nurse at Rochester General 16. Rome III Diagnostic Criteria for Functional www.worldgastroenterology.org/assets/export/ Hospital in Rochester, N.Y. Edith Claros is an associate professor of nursing at Massachusetts College of Gastrointestinal Disorders. http://www. userfiles/05_constipation.pdf. romecriteria.org/assets/pdf/19_RomeIII_ Pharmacy and Health Sciences in Worcester, Mass. apA_885- 898.pdf. 24. Moultry AM, Godley CB, Wanami M. A review of peripherally acting mu-opioid receptor antagonists. The authors and planners have disclosed that they 17. Ackley BJ, Ladwig GB. Nursing Diagnosis Formulary. http://www.modernmedicine.com/ have no financial relationships related to this article. Handbook: An Evidence-Based Guide to Planning Care. modernmedicine/article/articleDetail.jsp?id= 9th ed. St. Louis, MO: Mosby Elsevier; 2011. 705809. DOI-10.1097/01.NURSE.0000422642.83383.17

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